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Spreads Enriched with Three Different Levels of Vegetable Oil Sterols And European Journal of Clinical Nutrition (1999) 53, 319±327 ß 1999 Stockton Press. All rights reserved 0954±3007/99 $12.00 http://www.stockton-press.co.uk/ejcn Spreads enriched with three different levels of vegetable oil sterols and the degree of cholesterol lowering in normocholesterolaemic and mildly hypercholesterolaemic subjects HFJ Hendriks1*, JA Weststrate2, T van Vliet1 and GW Meijer2 1TNO Nutrition and Food Research Institute, Zeist, The Netherlands; and 2The Unilever Nutrition Center, Unilever Research, Vlaardingen, The Netherlands Objective: To investigate the dose-response relationship between cholesterol lowering and three different, relatively low intake levels of plant sterols (0.83, 1.61, 3.24 g=d) from spreads. To investigate the effects on lipid- soluble (pro)vitamins. Design: A randomized double-blind placebo controlled balanced incomplete Latin square design using ®ve spreads and four periods. The ®ve study spreads included butter, a commercially available spread and three experimental spreads forti®ed with three different concentrations of plant sterols. Subjects: One hundred apparently healthy normocholesterolaemic and mildly hypercholesterolaemic volunteers participated. Interventions: Each subject consumed four spreads, each for a period of 3.5 week. Results: Compared to the control spread, total cholesterol decreased by 0.26 (CI: 0.15 ± 0.36), 0.31 (CI: 0.20 ± 0.41) and 0.35 (CI: 0.25 ± 0.46) mmol=L, for daily consumption of 0.83, 1.61 and 3.24 g plant sterols, respectively. For LDL-cholesterol these decreases were 0.20 (CI: 0.10 ± 0.31), 0.26 (CI: 0.15 ± 0.36) and 0.30 (CI: 0.20 ± 0.41). Decreases in the LDL=HDL ratio were 0.13 (CI: 0.04 ± 0.22), 0.16 (CI: 0.07 ± 0.24) and 0.16 (CI: 0.07 ± 0.24) units, respectively. Differences in cholesterol reductions between the plant sterol doses consumed were not statistically signi®cant. Plasma vitamin K1 and 25-OH-vitamin D and lipid standardized plasma lycopene and alpha-tocopherol were not affected by consumption of plant sterol enriched spreads, but lipid standardized plasma (alpha beta)-carotene concentrations were decreased by about 11 and 19% by daily consumption of 0.83 and 3.24 g plant sterols in spread, respectively. Conclusions: The three relatively low dosages of plant sterols had a signi®cant cholesterol lowering effect ranging from 4.9 ± 6.8%, 6.7 ± 9.9% and 6.5 ± 7.9%, for total, LDL-cholesterol and the LDL=HDL cholesterol ratio, respectively, without substantially affecting lipid soluble (pro)vitamins. No signi®cant differences in cholesterol lowering effect between the three dosages of plant sterols could be detected. This study would support that consumption of about 1.6 g of plant sterols per day will bene®cally affect plasma cholesterol concentrations without seriously affecting plasma carotenoid concentrations. Sponsorship: Unilever Research Vlaardingen, NL Descriptors: cholesterol-lowering diet; plant sterols; dosage; spreads; lipid soluble (pro)vitamins Introduction varying between 3 and 6% (Tang et al, 1998). Dietary factors contributing signi®cantly to a reduction of total One of the major modi®able risk factors for coronary heart cholesterol by dietary advice include high concentrations of disease (CHD) mortality is plasma cholesterol concentra- linoleic acid and low concentrations of saturated fatty acids tion. Several large scale intervention trials have shown that (Keys et al, 1965; Mensink & Katan, 1992; Katan et al, cholesterol lowering drug therapy in hypercholesterolaemic 1994). patients bene®cially affects CHD mortality risk (Gould et The cholesterol lowering properties of plant sterols have al, 1998). Mildly hypercholesterolaemic subjects usually been known since the 1950s (Pollak, 1952). High dosages have dietary guidelines prescribed as a ®rst treatment to of plant sterols have been applied to lower plasma choles- lower their blood cholesterol. Normocholesterolaemic sub- terol concentrations in hypercholesterolaemic subjects jects may apply such a diet as a part of a healthy life-style. (Ling & Jones, 1995). No obvious side effects have been However, the percentage reduction in blood total choles- observed in humans, except in individuals with phytoster- terol attributable to dietary advice is modestly effective in olemia (LuÈtjohann & Bergmann, 1997). The mechanisms free-living subjects; that is a reduction of total cholesterol of hypocholesterolaemic action may include inhibition of cholesterol absorption (Pollak & Kritchevsky, 1981). *Correspondence: Dr HFJ Hendriks, TNO Nutrition and Food Research Recently, it was suggested that substitution of sitostanol- Institute, PO Box 360, 3700 AJ Zeist, The Netherlands. Received 4 August 1998; revised 12 November 1998; accepted ester enriched spread for a portion of normal dietary spread 24 November 1998 is suitable as a strategy to reduce serum cholesterol in the Cholesterol lowering effect of plant sterols HFJ Hendriks et al 320 population. A one-year intervention study (Miettinen et al, apparently healthy. Health status was assessed by disease 1995) showed that consumption of sitostanol-ester enriched history questionnaire, physical examination and routine spread by subjects with mild hypercholesterolaemia was blood chemistry. Eligible subjects did not suffer from effective in lowering serum total cholesterol and LDL chronic gastrointestinal complaints and=or cardiovascular cholesterol by 10 and 14%, respectively. Sitostanol-ester, disease, high blood pressure (according to WHO guide- which is derived from hydrogenation of sitosterol from pine lines), high blood cholesterol (fasting serum total choles- tree woodpulp and subsequently esteri®ed with a free fatty terol < 7.5 mmol=L). They also did not use prescribed acid, is not the only effective cholesterol lowering plant medication (except oral contraceptives) and were not on a sterol. Sterols from commonly used edible oils (soybean, diet for medical reasons. Eligible subjects reported inten- rapeseed and sun¯ower oils), that is the 4-desmethylsterols sive exercise for not more than 10 h=week, consumption of sitosterol, campesterol and stigmasterol, have a similar a habitual Dutch diet including the use of spreads (assessed cholesterol lowering effect (Weststrate & Meijer, 1998). by dietary questionnaire) and consumption of alcoholic However, plant sterols, including stanols, may also beverages for less than 22 units=week when female and lower plasma concentrations of other lipophilic compounds for less than 29 units=week when male. as reported for carotene, lycopene and alpha-tocopherol (Weststrate & Meijer, 1998; Gylling et al, 1996). There- Experimental design fore, an optimal plant sterol or stanol intake level has to be The study had a double-blind, placebo-controlled, balanced selected, reducing cholesterol concentrations optimally, but incomplete Latin square design using ®ve spreads and four having minimal effect on other lipophilic compounds. periods. This design controls for between subject variation Relatively few studies, however, have evaluated the dose- and for variation over time. In addition this design results in effect relation of dietary plant sterols or stanols. Usually a balanced randomization of treatment orders over the one intake level has been applied in ef®cacy studies using subjects, so that any systematic effect of the order in mildly hypercholesterolaemic subjects. Sitostanol and which treatments were given will not create bias in the sitostanol ester dosages in the various studies ranged comparison of the treatment means. Subjects received in from 0.7 g=d (Miettinen & Vanhanen, 1994) to 3.4 g=d four consecutive periods of 24 or 25 d (3.5 weeks) 25 g (Pollak, 1952). Miettinen et al, 1995 compared 1.8 g=d spread per day. The included subjects were randomly and 2.6 g=d of sitostanol ester in the second part of his allocated to the spreads. One hundred volunteers were study showing a slightly stronger cholesterol lowering included and consequently data were obtained for each effect of the high dose on both total and LDL cholesterol. spread from eighty subjects. The ®ve spreads included Sitosterol has been consumed in dosages ranging from butter and a control spread, that is a commercially available 0.7 g=d (Miettinen & Vanhanen, 1994) to 6 g=d (Weisweiler spread Flora (Van den Bergh Foods, Crawley, UK) and et al, 1984) in hypercholesterolaemic subjects and soy bean three test spreads, which were spreads forti®ed with three oil sterols in dosages from 0.7 g=d (Pelletier et al, 1995) to concentrations of plant sterols, namely 3.37% (w=w), 3.0 g=d (Mensink & Katan, 1992) in normocholesterolae- 6.47% (w=w) and 13.06% (w=w) derived from commonly mic and mildly hypercholesterolaemic volunteers. used edible oils. These three test spreads should provide The main objective of this present study was to inves- 0.85 g=d, 1.62 g=d and 3.26 g=d of plant sterols, respec- tigate the dose-dependency of the cholesterol-lowering tively, assuming 100% compliance of the subjects to the effects of three relatively low dosages, namely 0.83, 1.61 treatments. Flora has a very similar fat composition as the and 3.24 g=d, of plant sterols derived from commonly used spreads containing plant sterols, and was used as the control edible oils in spreads. These three spreads, and a control spread for the quantitative evaluation of the cholesterol spread of similar fatty acid composition but not enriched in lowering effects of plant sterols. Butter was used as alter- plant sterols and butter were used by normocholesterolae- native,
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